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The prevalence, aetiology and
management of wounds in a
community care area in Ireland
Abstract
This study aimed to establish the prevalence and
aetiology of wounds, allowing an insight into the
management of wound care, the use of dressings
and the nursing time allocated to the provision of
wound care in a community setting in Ireland.
A cross-sectional survey was used, with data
collected on all clients in the community who
received treatment from public health nurses or
community registered general nurses for wound
care over a 1-week period in April 2013. A 98.9%
response rate was realised, and 188 people were
identified as having wounds, equating to a crude
prevalence of 5% of the active community nursing
caseload. A total of 60% (n=112) had leg ulcers,
22% (n=42) had pressure ulcers, 16% (n=30) had
Key words:
Wound prevalence
an acute wound (surgical or traumatic wounds), 1%
(n=2) had a diabetic foot wound and a further 1%
(n=2) had wounds of other aetiologies. The mean
duration of wounds was 5.41 months. A total of
18% of wounds were identified as infected; however, 60% (n=112) of wounds had antimicrobial
products in use as either a primary or secondary
dressing. The study established that there is a significant prevalence of wounds in this community
care area. There was absence of a clinical diagnosis in many cases, and evidence of inappropriate
dressing use, risking an increase in costs and a
decrease in good clinical outcomes. It also highlighted the importance of ongoing education and
auditing in the provision of wound care.
Appropriate dressings
Louise Skerritt
email: louise.skerritt@hse.ie
Public Health Nurse/Tissue Viability Nurse, Health
Service Executive, Dublin Mid-Leinster
Zena Moore
Professor and Head of School of Nursing &
Midwifery, Royal College of Surgeons in Ireland
Nursing resources
acceptable to both patients and staff (Gethin et al, 2005;
Vowden and Vowden, 2008). At this point, there is a dearth of
information regarding this clinical burden related to chronic
wounds within the Irish health-care setting (Balanda et al, 2005;
Clarke-Maloney et al, 2006; Laurant et al, 2006).Thus, as there
is little evidence to determine the prevalence and aetiology of
wounds in a community area, including the resources allocated
to the provision of wound care, it is pertinent to conduct a
study to enhance the understanding of this clinical problem
(McDermott-Scales et al, 2009).
Accepted for publication 9 MAY 2014
Wound management
© 2014 MA Healthcare Ltd
W
ound management is responsible for approximately
4% of the annual UK health-care budget (Posnett
and Franks, 2007).There are no exact figures
relating to how much of the Irish health-care budget is spent
on wound care of all aetiologies; however, the cost of the
management of chronic wounds to the Irish Health Service
Executive (HSE) is estimated at €285.5 million per year
(McDermott-Scales et al, 2009). In today’s fiscally challenging
climate, it is imperative that service managers and planners
adopt clinical interventions that are effective, efficient and
In general, wound management is costly and challenging with
respect to current health services’ scarce resources (Moore and
Cowman, 2005;Vowden and Vowden, 2008; HSE, 2009;Vowden
et al, 2009; Cooper et al, 2010;). Although wound care has been
brought to the forefront in terms of education and research,
neither the incidence nor prevalence of wounds is reducing
(Moore and Cowman, 2005; Dini et al, 2006; European Pressure
Ulcer Advisory Panel (EPUAP) and National Pressure Ulcer
Advisory Panel (NPUAP), 2009). Wound management involves
more than just selecting the right dressing—all factors that affect
healing rates must be considered when treating chronic wounds
(Moore and Cowman, 2005; Chandan et al, 2009).
Community Wound Care March
June 2014
2014
tish Journal of Community Nursing.Downloaded from magonlinelibrary.com by 193.061.135.034 on June 28, 2015. For personal use only. No other uses without permission. . All rights reserv
Clinical focus:
Community wound study
Approaches to health care have changed over the last decade,
with a greater emphasis being placed on primary care, resulting in
new challenges in the wound management in community nursing
services (Laurant et al, 2006; HSE, 2009; McDermott-Scales et al,
2009).To provide cost-effective, quality wound care, it is important
to have an understanding of the extent of the burden wound
management places on community services (Posnett and Franks,
2007;Vowden and Vowden, 2008;Vowden et al, 2009). Having
information regarding the number of wounds in a community care
setting and their associated aetiology will provide nurses and nursing
managers with an insight into the specific needs of these clients and
may also highlight areas where care or services can be improved
or further developed (Vowden et al, 2009).Changing population
demographics and the predicted rise in the number of older people
in the future suggests that there will be a corresponding increase in
the number of people with wounds, highlighting the importance
of implementing effective management strategies (Moore and
Cowman, 2005; HSE, 2009;Vowden and Vowden, 2008;Vowden et
al, 2009; Chandan et al, 2009).
Method
This was a single-site cross-sectional descriptive survey,
employing a purposive sampling strategy. This research was
carried out in a large community care area in Ireland that has a
defined population of 118 379 (Central Statistics Office, 2011).
This community area incorporates 16 health centres, 8 of
which are in built-up urban areas and 8 of which are in large
rural geographical areas. There were 14 communiy registered
general nurses (CRGNs) with varying contractual working
hours (equating to 8 full-time CRGNs), plus the equivalent of
17 area public health nurses (PHNs) (see Box 1) working in this
community setting during the week of the study. During the
week of the survey, the active caseload was 3596, all of whom
were over 18 years of age. Data were collected pertaining to each
client with a wound, over a 1-week period by CRGNs or PHNs
who provided direct wound management for the clients.
Inclusion and exclusion criteria
The clients were given information sheets pertaining to the study,
and written consent was obtained from each client participating
in the study. Therefore, the exclusion criterion was expanded to
include those with psychological disorders, dementia and clients
for whom English was not their first language.
Ethical approval
Box 1. Role of the public health
nurse and community registered
general nurse in Ireland
The public health nurse’s (PHN’s) role is traditionally
described as ‘generalist’ with caseloads including all age
ranges from newborns to the older person. PHNs work
as part of a multidisciplinary team in providing primary
care and secondary prevention to a broad range of client
groups including children, older people, new mothers,
families, those who are terminally ill, and both adults and
children with complex disabilities (Hanafin, 1997). A PHN is
the caseload manager and works in a specific geographical
area that is locally situated in a health centre (Hanafin and
Cowley, 2003). The community registered general nurse
works closely with and supports the PHN service as part
of a community nursing team in accordance with a care
plan developed with a PHN for clients of 18 years and older
(Department of Health and Children, 2000).
determine the prevalence and aetiology of wounds; however, data
retrieved has also provided further information regarding wound
management. This is due to the inclusion of questions that
retrieved the following information:
The length of time required to travel to the client
The nursing time for the provision of wound care
The number of clients receiving full vascular assessments
The frequency of dressing changes.
Pilot study
A pilot study was carried out to test the proposed method of data
collection (Anderson et al, 2013).The reliability and validity of
the data submitted was dependent on the nurses completing the
questionnaire. Therefore, education sessions were organised for
the participating nurses before the study. These efforts increased
the consistency of data collection.
Data analysis
Data were analysed using SPSS 20. In the main, simple
descriptive analysis was conducted with the results expressed as
percentages, including analysis of the dispersion of data. Point
prevalence was calculated as a percentage by comparing the
number of people with a wound with the total number of
persons in the population at the specific point in time.
Results
To allow the commencement of this study, ethical approval was
sought from the research ethics committee. Local approval from
the site of the research was also granted.
All of the CRGNs and PHNs in the community care
area participated in the study and returned 188 completed
questionnaires, yielding a response rate of 98.9% (two clients
were excluded due to dementia).
Data collection
Total number of wounds
The researcher was granted permission to use a specific wound
prevalence and aetiology questionnaire (Vowden et al, 2009). The
questionnaire was modified to include the travel time, location
of wound management and whether the nurse was working in
a rural or urban area. The main aim of this questionnaire was to
During the specified week of the wound study, a total of
188 clients with 297 wounds were identified by CRGNs and
PHNs as requiring wound management (point prevalence 0.1%).
Furthermore, 58% (n=110) of clients presented with one wound,
and the remaining 42% (n=78) had between 2 and 5 wounds.
© 2014 MA Healthcare Ltd
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Clinical focus:
Community wound study
Wound care providers
The CRGNs provided 70% (n=132) of the wound care and the
remaining 30% (n=56) was provided by PHNs. Urban areas had
a slightly higher clinical caseload, treating 62% (n=117) of the
wounds, compared to 38% (n=71) of the wounds being treated
in the rural setting. However, only 22% (n=42) of these wounds
were treated in a wound clinic. Thus, 78% (n=146) of clients had
their wounds managed in their home.
Demographics
The age of the clients varied from 28 to 98 years, with a mean
age of 72.5 years. There were more women (71%, n=133)
receiving wound management. The presence of contributing
medical problems was also recorded, and 85% (n=159) of the
clients had an underlying medical condition. Unsurprisingly,
the majority of clients (55%, n=63) with any form of leg ulcer
presented with vascular disease. Diabetes was also noted to be
predominant among clients with leg ulcers, mainly these clients
presenting with venous ulcers (46%, n=16) and 37% (n=13) of
clients with unclassified leg ulcers.
Wound aetiologies
Table 1 provides an outline of the wound aetiology by client.
The most common wound reported was leg ulceration, which
accounted for 60% (n=112) of all clients. Among these clients,
venous leg ulcers presented the most often, accounting for
55% (n=61) of wounds, whereas 3% (n=4) were classified as
arterial, 8% (n=9) were classified as mixed (arterial/venous
ulcer), 2% (n=2) presented with neuroischaemia and 32% (n=36)
were unclassified. A total of 22% percent of clients (n=42) had
a pressure ulcer (point prevalence 0.04%). Of these wounds,
50% (n=21) were grade 2, whereas 17% (n=7) were grade 1,
with 26% (n=11) and 7% (n=3) grade 3 or grade 4 respectively
(Table 1). Of the 42 pressure ulcers reported, 74% (n=31)
occurred in women and 26% (n=11) in males.
Of the remaining clients, 16% (n=30) had an acute wound
either due to surgery or trauma, whereas 1% (n=2) had either a
fungating breast wound or a radiation burn. Only 1% of clients
(n=2) had a diabetic foot wound.
© 2014 MA Healthcare Ltd
Wound duration and size
The mean duration of the wound being present was
5.41 months, ranging from less than 1 week to 20 years. Around
a third of wounds (36%, n=67) were recurrent, while the
remainder (64%, n=117) were diagnosed as primary wounds.
Interestingly, 52% (n=59) of leg ulcers were noted as being
recurrent wounds, compared to 33% (n=14) of pressure ulcers.
The mean size of wounds was established to be 2.34cm2,
ranging from <2cm2 to <25cm2. For 36% (n=68) of clients,
their wound surface area measured <2cm2, whereas a further
35% (n=66) of clients presented with a wound size of 2–5cm2
(Table 2).
Diagnosis of wounds
In this section of the questionnaire, respondents were requested
to tick as many answers as were relevant; thus, it was possible
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Table 1. Wound aetiology by client
Wound type
Number
%
Leg ulcer
112
60
Pressure ulcer
42
22
Diabetic foot ulcer
2
1
Acute wound
30
16
Other wound
2
1
Total
188
100
Table 2. Wound size by client
Frequency
Number
%
<2cm2
68
36.2
2–5cm2
66
35.1
5–10cm2
20
10.6
10–25cm2
13
6.9
<25cm2
13
6.9
Closed surgical
wound
1
0.5
Not applicable
7
3.7
Total
188
100
that nurses could report more than one method to diagnose the
wound aetiology. The most frequently reported methods were
medical history, nursing history, physical examination and visual
examination (62.8%, n=118; 56.9%, n=107; 70.2%, n=132; 69.1,
n=130, respectively). Of clients with leg ulcers, only 43% (n=50)
were assessed using Doppler studies.
Pressure ulcer prevention practices
Just 69% (n=29) of those with pressure ulcers had a risk
assessment carried out, and only 40% (n=17) had the result
recorded in the clinical notes. Interestingly, some patients with
existing pressure ulcers (19%, n=8) were determined not to
require risk assessment. Where pressure ulcers were evident,
54% (n=23) were reported to have developed in the patient’s
home. However, only 4% (n=2) had a pressure ulcer incident
reporting form completed. Pressure relieving equipment was
made available to 22% (n=9) of clients with pressure ulcers
and 7% (n=13) had a planned schedule for repositioning.
Interestingly, two of the three (66%) clients with grade 4 pressure
ulcers did not have a planned schedule for repositioning.
Dressing use
A wide variety of dressings were in use, although not always
appropriately. For example, for wounds that were necrotic (7%,
n=13), 2% (n=5) had a non-adherent (impregnated with soft
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tish Journal of Community Nursing.Downloaded from magonlinelibrary.com by 193.061.135.034 on June 28, 2015. For personal use only. No other uses without permission. . All rights reserv
Clinical focus:
Community wound study
paraffin) dressing applied. Furthermore, 17% (n=32) of wounds
were noted to have a problem with exudate management, and
of these highly exuding wounds, 31% (n=10) were dressed with
a low-adherent dressing. The majority of wounds (79%, n=148)
were found not to have a problem with exudate. However, of
these low-exuding wounds, 31% (n=46) were dressed with an
absorptive dressing (data are missing for 3% (n=7) wounds). In
addition, in 76% (n=144) of clients, no infection was suspected
in their wounds. However, of these non-infected wounds, an
antimicrobial dressing was used as the primary wound dressing
in 42% (n=61) of cases. It is important not to use antimicrobial
dressings when infection is not present, or when there is no
significant risk of infection, as some of these dressings can result
in damage to healthy tissue (Vowden et al, 2011; Schultz and
Dowsett, 2012; Weir, 2012).
Discussion
The time taken to travel to patients located in the community
and the time required to treat all wounds was reported for
all 188 wounds. Only a small number (22%, n=42) of clients
did not require the nurse to travel to them as they attended a
wound dressing clinic. The mean travel time was 14.53 minutes,
varying from 5 minutes to 40 minutes.
The most common wound reported was leg ulceration, which
accounted for 61% of all wounds. However, this figure may
be underestimated by the fact that 31% of these patients’ ulcer
aetiologies were undiagnosed or unknown. A previous Irish
study also recorded a substantially high percentage (42%) of
undiagnosed leg ulcers (McDermott-Scales, 2009).These figures
were similar in the UK, where 26% of wounds classified as leg or
foot ulcers had no definite diagnosis (Drew et al, 2007).
Leg ulceration is a considerable health problem in Ireland,
having a debilitating effect on clients and a substantial effect on
health-care budgets (HSE, 2009).Therefore, individuals need to be
correctly and efficiently assessed to provide the most appropriate
treatment, ensuring cost effective, evidence-based wound care
(Clarke-Maloney et al, 2008; Coldridge-Smith, 2009).
The similarities between the current study and published
literature (Clarke-Maloney et al, 2008; McDermott-Scales, 2009)
raise concerns regarding the appropriate management of leg
ulcers. These studies concur that there is a problem surrounding
undiagnosed leg ulceration and a lack of full clinical and holistic
assessment, which in turn pose a real problem for effective
wound management. A lack of an accurate assessment and
diagnosis impacts negatively on good clinical outcomes being
achieved in individuals with leg ulceration. Furthermore, this
will increase the financial cost of these problematic wounds to
the health-care service, while also adding to the psychological,
physical and social impact that these wounds place on the
individual (Drew et al, 2007; Clarke-Maloney et al, 2008; HSE,
2009; Chandan et al, 2009).
Frequency of dressing change
Compression therapy
The frequency of dressing changes varied from daily to onceweekly. The 5% (n=9) of wounds that were dressed daily
took 2 hours and 18 minutes of travel time per week. A total
of 20% (n=38) of wounds were dressed three times a week,
equating to 28 hours of travel time. Twice-weekly was the most
common frequency of dressing change (58%, n=110), equating
to 53 hours and 27 minutes in travel time. The remaining
wounds (16%, n=31) were dressed once a week equating to
7 hours and 50 minutes of travel time. The total time that
community nurses spent travelling minus the 22% (n=42) that
were treated in-clinic was 81 hours and 18 minutes.
The use of high compression bandages in the treatment of
venous leg ulcers is uncontested, as the evidence has shown that
compression therapy can enhance healing rates by up to 70% at
12 weeks (Gethin, 2009; Jorgensen, 2008; Moffatt et al, 2009).
Furthermore, applying compression therapy in conjunction with
a programme to prevent ulcer recurrence can improve patients’
quality of life and reduce the financial and resource burden of
venous ulcer disease on health-care services (Grace, 2003; Gethin,
2009; Posnett et al, 2009).
In this study, compression therapy was used in only 53% of
clients with venous leg ulcers. The lack of use of compression
in some cases may have been due to a lack of confidence
regarding the underlying arterial status of the affected clients,
as only 43% had been assessed using the hand-held Doppler.
Nonetheless, what is apparent is that individuals with venous leg
ulceration managed in this community setting are not always
offered treatments in keeping with national and international
best practice (Grace, 2003; Gethin, 2009; Posnett et al, 2009;
Finlayson et al, 2010). As leg ulceration is frequently chronic
and relapsing in nature, it is essential that patients have early
access to diagnostic and vascular assessments so that the best
possible outcomes are achieved and patient suffering is reduced
(Drew et al, 2007; HSE, 2009; Moffatt et al, 2009). Inappropriate
management compounds fiscal challenges and exacerbates the
Compression therapy
Compression therapy was used in 53% (n=32) of clients with
venous leg ulcers. Of these, three-layer compression therapy
was the most common (9%, n=16), followed by four-layer
compression (6%, n=12), the remaining 3% (n=6) used shortstretch bandaging, compression stockings or the Unna boot.
Travel time
Time spent on wound management
The mean time taken to treat a wound was 20.1 minutes,
varying from 5 to 60 minutes. The total number of clients
identified was 188 and, as already outlined, some of these
clients had more than one wound. The mean number of
wounds per client was 1.56, equating to 293 wounds. The mean
frequency of dressing changes was three per week, equating
to a total of 879 dressing changes. The number of dressings
(879) was multiplied by the mean time calculated to perform
dressing changes (20 minutes). The total time for the provision
of wound management in this Irish community setting was
therefore calculated at 293 hours a week.
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Clinical focus:
Community wound study
negative impact that the presence of these wounds has on client
and community nursing service resources (Clarke-Maloney, 2006;
Drew et al, 2007; Jorgensen, 2008;Vowden and Vowden, 2008;
Gethin, 2009).
Pressure ulcers: risk assessment
Pressure ulcer prevention and management is of great importance
in today’s fiscally challenging health-care environment (EPUAP
and NPUAP, 2009; Moore and Cowman, 2011). Indeed, the
literature states that most pressure ulcers can be prevented with
little or no additional expense (Moore and Cowman, 2011;
Suriadi et al, 2008). The completion of a risk assessment tool
is one of the first steps in the prevention of pressure ulcers
(Jordan-O’Brien and Cowman, 2011) and, as such, 70% of the
respondents stated that a risk assessment had been completed
for the client. However, only 40% of the questionnaires had the
result of the risk assessment recorded. Surprisingly, some patients
with existing grade 2 and grade 3 pressure ulcers (19%) were
classified as not requiring risk assessment.
Increased risk of pressure ulcers
Community care providers are delivering services to an
increasingly ageing population, yet this vulnerable population
is facing a growing prevalence of chronic disease and disability
(Gethin et al, 2005; HSE, 2009; Moore and Cowman, 2011).
There is a positive association between the development of
pressure ulcers and age; thus, older individuals are at significantly
increased risk of developing pressure ulcers (Moore and
Cowman, 2001; HSE, 2009; EPUAP and NPUAP, 2009).
Therefore, it is important that there is a consistent methodology
applied for pressure ulcer prevention within the community
care setting (McDermott-Scales et al, 2009; Chandan et al,
2009). However, the findings from this study note an unreliable
approach and reflect what seems to be a level of confusion
around pressure ulcer management and prevention. From a
patient safety perspective this is not acceptable, as it means that
vulnerable individuals will be placed at increased risk (Gethin et
al, 2005; Chandan et al, 2009; Moore and Cowman, 2011; Moore
et al, 2011; Moore and Van Etten, 2011).
© 2014 MA Healthcare Ltd
Appropriate use of dressings
The overarching goal from the perspective of dressing selection
is to provide an environment at the wound dressing interface
that is conducive to achieving healing (Harding, 2007; Moore
and Cowman, 2011). Therefore, the selection of an appropriate
dressing should be made bearing in mind the wound bed
condition and the requirement to prevent the wound bed from
drying out, or, conversely, to manage excess fluid that may cause
maceration to the surrounding skin (Gray et al, 2005; Schultz and
Dowsett, 2012). There are patient-related factors that should be
considered as they can influence the management of care. These
factors should also be acknowledged and addressed by the healthcare provider to ensure that the selected dressing enhances the
quality of patient care (Edwards, 2003; Finlayson et al, 2010). The
findings of this study clearly demonstrate that dressing selection
caused some confusion among CRGNs and PHNs regarding
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the most appropriate dressing to apply to infected wounds and
exudating wounds.
Wound exudate
Wound exudate is produced in response to a complicated
interaction between wound environment, wound healing and
compounding pathological processes (Harding, 2007; Schultz
and Dowsett, 2012). However, exudate may become a problem
for the patient or caregiver when the quantity produced delays
or prevents wound healing (White and Cutting, 2006; StephenHaynes et al, 2011), causes physical and psychosocial morbidity
and increases the demand on health-care resources (Spilsbury et
al, 2007).
The majority of wounds (79%, n=148) were found not to
have a problem with exudate. However, of these low-exuding
wounds, 31% (n=46) were dressed with an absorptive dressing.
Use of absorptive dressings when there is little exudate may result
in these dressings adhering to the wound, causing damage to the
wound bed and unnecessary pain to the client.
In contrast, 17% (n=32) of wounds were noted to have a
problem with exudate management, and of these highly exuding
wounds, 31% (n=10) were dressed with a low-adherent dressing.
The inappropriate use of dressings for exudating wounds can
increase the risk of infection, delay healing and cause the skin
surrounding the wound to become macerated (Harding, 2007;
White and Cutting, 2006; Stephen-Haynes, 2011). Unsuccessful
management of wound exudate can also affect the physical, social
and psychological aspects of a client’s life (Hopkins et al, 2006;
Spilsbury et al, 2007).
Wound infection
In 76% (n=144) of clients, no infection was suspected in
their wounds. However, of these non-infected wounds, an
antimicrobial dressing was used as the primary wound dressing
in 42% (n=61) of cases. Antimicrobial dressings should only be
considered after thorough assessment and investigation, and they
should not be applied when infection is not present, or when
there is no significant risk of infection, as some of these dressings
can result in damage to healthy tissue damage (Vowden et al,
2011; Moore, 2013).
Dressings represent a small proportion of the total cost of
wound care. However, if dressings are used inappropriately, this
can place a disproportionate amount of influence on the other
factors that will increase the wound care cost (Grace, 2003; Moore
et al, 2011). Furthermore, deviations from appropriate dressing
selection may lead to delay in healing, thereby increasing both
human and economic cost (Chandan et al, 2009; Fife et al, 2010).
Cost
There has been an increasing awareness of costs related to
wound care in recent years, but economic analyses are still
largely lacking (Drew et al, 2007; Posnett and Franks, 2007).
This survey found the average time required for both travel and
wound management, and, when calculated with the frequency of
dressing changes, the final figure for the time community nurses
spend on wound care provision was calculated to be 374 hours
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tish Journal of Community Nursing.Downloaded from magonlinelibrary.com by 193.061.135.034 on June 28, 2015. For personal use only. No other uses without permission. . All rights reserv
Clinical focus:
Community wound study
a week. The time required for wound care was equivalent to
18.5 part-time CRGNs. Currently, in this community care area,
there are the equivalent of 14 part-time CRGNs. Therefore, the
level of wounds in this community care area is responsible for
over 100% of the CRGN workload.
The PHN is the caseload manager for child health and
the older person, and, unlike a decade ago, PHNs (alongside
CRGNs) now provide wound care, end-of-life care, clinical
assessments, incontinence assessments, hospital discharge visits,
home help reviews and home care package applications and
reviews. The clinical aspect of the PHN role has had to change
because of the increasing clinical demands placed on CRGNs,
and this was reflected in this study, showing that they provided
30% of the wound care. Nurse time is an important factor in
the process of analysing cost for wound care; this information
is currently not available for the Irish health service. However,
in the UK, nurse time was estimated to account for 33–41% of
the overall cost of wound care (Chandan et al, 2009). These data
demonstrate that the impact of nursing time required for the
provision of wound care is often an underestimated or hidden
cost to health-care organisations. Having information such
as the use of nursing resources, which this study presented as
374 actual nursing hours, will enable the measurement of nursing
time allocated to wound management. This will serve in turn to
inform service managers and planners and, in doing so, assist with
decision-making when allocating budgets and resources.
provision of a community-based nurse-led leg ulcer clinic,
providing timely, expert assessments and a broader range of
diagnostic methods for clients with acute and chronic wounds
within a collaborative multidisciplinary care framework. This
service would prove to be cost-effective, reducing resources
by promoting best standards in tissue viability and wound
management practices across a community-based nursing
service. A tissue viability nurse would act as a resource
of information for all members of the community-based
interdisciplinary team and contribute to staff development
through education leadership and collaboration (Vowden and
Vowden, 2008; HSE, 2009; Clarke-Maloney et al, 2008; Moffatt
et al, 2009). The ultimate goal of educating CRGNs and
PHNs in wound care must be to improve patient outcomes.
A structured programme of training for practitioners involved
in wound care, supported by best practice guidelines, has
the potential to reduce the variation in clinical practice and
improve patient outcomes (Drew et al, 2007; Clarke-Maloney
et al, 2008; Colridge-Smith, 2009; Moffatt et al, 2009).
This study recorded the wounds treated by the community
nursing service, not individuals who attended outpatient
departments, GP services or who treated their own wounds.
Therefore, it may not be a true measure of the prevalence of
wounds in the community setting.
Strengths and limitations
Wounds do not have a one-dimensional impact but rather can
affect three domains; that is, the individual, the health service
and society. There is a growing body of evidence that suggests
that a structured, organised and planned approach to wound
management—whether for specific wound aetiologies or for
wounds in general—improves patient outcomes and is cost
effective for the health service (Department of Health and
Children, 2000; Balanda et al, 2005; Jorgensen, 2008; Chandan
et al, 2009). However, without baseline information we cannot
identify areas of strength or weakness (Cooper et al, 2010). It
is therefore essential to have information about care provided
with a view to ensuring that it is both clinically effective and
cost effective (Posnett and Franks, 2007).
This study has highlighted the amount of time required
by the community nurse for the provision of wound care.
Furthermore, it highlights a major cost to the community
health service incurred by wounds, during a time of intense
pressure to deliver quality care within increasing financial
constraints and reduced numbers of community nurses.
Problems with chronic wounds and delayed healing will
continue to increase if the current trend of managing leg
ulceration (for example, for long durations without a holistic
assessment) prevails. The data from this study emphasise that,
irrespective of aetiology, problematic wounds are a common
and very expensive health-care problem with community
nurses being the main providers of care (Vowden and Vowden,
2008; HSE, 2009;Vowden et al, 2009; Anderson et al, 2013).
This, combined with changing approaches to health-care
provision, with its emphasis on primary care, is resulting in new
The methodology used for this study was effective in gathering
the information required; however, the reliability and validity
of the data submitted was dependent on the professional
completing the form, their level of experience and knowledge
with regard to wound care. Despite all attempts made by the
author, there is no guarantee that all clients receiving wound
care from community nursing services were included.
Recommendations
To enhance treatment of wounds in this community care
area an integrated approach to wound care is needed, with a
clear strategy and policy supported by management. Wound
care is an area where there is evidence of a wide variation
in practice, some of which may not be effective, rendering
it time consuming and costly to both clients and the health
service. Internationally, the benefits of nurse-led specialist
services in primary wound management, with direct access to
multidisciplinary teams, has demonstrated faster healing times,
reduced prevalence rates, reduced variation in wound care
practice and improved quality of life for clients, while providing
an evidence-based, cost-effective service that is both equitable
and accessible (Clarke-Maloney et al, 2008;Vowden and
Vowden, 2008;Vowden et al, 2009).
The introduction of a tissue viability service in this
community care area would provide appropriate interventions
for the diagnosis of wounds, thereby improving client outcomes
and reducing demands on acute care services. The population
of clients with leg ulcerations can be addressed through the
Conclusion
© 2014 MA Healthcare Ltd
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Community Wound Care June 2014
tish Journal of Community Nursing.Downloaded from magonlinelibrary.com by 193.061.135.034 on June 28, 2015. For personal use only. No other uses without permission. . All rights reserv
Clinical
Clinical focus:
Community
Community wound study
challenges to the management and treatment of wounds in the
community (Drew et al, 2007;Vowden and Vowden, 2008; HSE,
2009;Vowden et al, 2009; Posnett et al, 2009). The findings of
this survey are an indicator of the significant impact wound
care has on health service resources. It also identifies areas for
further research, highlighting fundamental data for the future
planning of health-care resources, focusing on cost containment
while providing quality patient outcomes.
CWC
Acknowledgement
© 2014 MA Healthcare Ltd
The author would like to acknowledge the public health nurses and
community registered general nurses for their time, effort and support in
the gathering of data for this study.
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KEY POINTS
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Community Wound Care June 2014
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